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The study was performed at Prince George's County Hospital, a 290-bed, acute care teaching hospital and regional referral center located in Cheverly, Maryland, from August 2005 to February 2006. The hospital sponsors an internal medicine residency program with 42 residents. There are four medical teams in the wards; each one consists of a senior resident, two first-year residents (Interns), and two medical students under the supervision of an attending physician. All team members are changed every month to allow rotation of residents in the hospital wards. The general medical teaching service habitually admits ten to twelve patients in a twenty-four hour period. Medical residents and staff attendings have a subscription to MDConsult provided by the hospital. On average, there are three to four desktops available for physician's use at each nurse station. They are heavily used for Internet access, laboratory results, radiology reports, and patient records. There is no 802.11 wireless network in the hospital.
The study met the requirements of the Research Committee of the Prince George's Hospital Center; temporary approval was granted on July 14, 2005 and final approval on September 13, 2005. All participants signed informed consent. The study had two main components, an initial cross-sectional survey to assess the patterns of Internet and handhelds usage by residents and attendings of the internal medicine department, followed by a prospective interventional cohort study to address the feasibility of using smart phones to access online medical resources during daily clinical activities.
Pre-study Internet and handhelds use survey
The survey was conducted prior to the smart phones experience to assess the level of knowledge on medical Web resources among residents and staff attendings of the department, as well as to evaluate the patterns of usage of the Internet and PDAs among the group and if there were any differences related to the level of training and medical practice [see Additional file 1]. The survey was distributed on paper and filled during the department meetings and academic activities to allow all the house staff to complete. No incentives were offered to the respondents.
Smart phones cohort study
Special lectures were given on medical informatics, mobile computing and EBM practice. These lectures as well as training sessions and group workshops on the use of the smart phones and Medline searching tools available at the U.S. National Library of Medicine (NLM) were carried out before and during the period of the study as part of the monthly conference schedule of the Department of Internal Medicine. Additional one to one training was provided by the resident in charge of the project in order to instruct other residents, students and attendings on the use of the resources.
The NLM lent three Palm Treo650® smart phones for the medical teams. Phone service and unlimited wireless Internet access through the T-Mobile network was obtained by the hospital at a monthly cost of US$120. The phones were assigned on a monthly basis to medical teams rotating in the wards. They were available for the teams' use from 8 am to 4 pm, Monday to Friday and locked at the Internal Medicine Department's office during nights and weekends. The devices were used by team members under the attending physician's supervision to search for answers to clinical questions when the need arose during rounds, morning reports, noon conferences and other academic activities.
Evidence-based medicine resources developed at the NLM were used as gateways for accessing published articles. The smart phones' index page was "PubMed for Handhelds" http://pubmedhh.nlm.nih.gov [Figure 1]. This handheld-friendly Web page provided links to: MEDLINE, askMedline, Disease Associations (DA) and Patient Intervention Comparison Outcome (PICO). An access log was created on the NLM server through IP number identification of the mobile phones to observe smart phones utilization. These IP numbers were determined by testing and confirmed with the wireless service provider. Access to Websites outside of the NLM was not monitored.
All the interactions were Web-based and no special software was required. The teams had no restriction to access other on-line medical resources they considered important during their searches. We obtained feedback from users after their one-month rotation by a final questionnaire on usage and satisfaction with the smart phones, efficacy of real-time access to references, perception of the value of the medical information derived from Internet and self-reported global impact in the decision-making process [see Additional file 2]. In the study, we considered a search as effective when the information retrieved using smart phones resolved the specific clinical question and could be used for the team's discussion at the bedside regarding the diagnosis or management of a patient. In academic activities, the medical information was considered positive if it contributed new knowledge, brought up new medical advances or new thoughts that generated structured analysis.
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